Cantr
Search
Home
About Us
Our Mission
Member Farms
Our Programs
Hippotherapy
Therapeutic Riding
Riding Schedule & Calendar
Be a Part
Ride
Volunteer
Donate
Sign up for our e-newsletter
Contact Us
Skip to content
You are here:
Hippotherapy Contract
Hippotherapy Contract
Date
(*)
Invalid Input
(Effective for one year)
(*)
I have read and understood the terms of the Hippotherapy Contract
Invalid Input
Access the terms and conditions here
(*)
I have contracted with CAN-TR to give me/my child/my ward hippotherapy.
Invalid Input
RIDER INFORMATION
First Name
(*)
Please enter your first name.
Middle Initial
Invalid Input
Last Name
(*)
Please enter your last name.
Age
(*)
Invalid Input
Date of Birth
(*)
Invalid Input
(MM/DD/YYY)
Phone
(*)
Please enter a phone number.
Address
(*)
Please enter your address.
City
(*)
Please enter the state where you live.
State
(*)
Please enter the state where you live.
Zip Code
(*)
Please enter your zip code.
Home Phone
(*)
Please enter a phone number.
Work Phone
Invalid Input
Mobile Phone
Invalid Input
E-mail address
(*)
Please enter a valid email address.
Confirm e-mail address
(*)
Please confirm your e-mail address.
Name of Parent or Legal Guardian
(*)
Invalid Input
(If you are an adult, input "none")
Phone for parent or guardian
(*)
Invalid Input
(If you are an adult, input "none")
Parent/Guardian Address
Parent/Guardian Address is the same as mine.
Invalid Input
Address for parent or guardian
(If different from yours)
City
State
Zip Code
Name of Emergency Contact
(*)
Invalid Input
Relationship to you
(*)
Invalid Input
Phone for emergency contact
(*)
Invalid Input
Cost/Financial Assistance
(*)
I understand that I am responsible for the monthly cost of $520 unless applying for financial assistance.
I am applying for financial assistance.
I am not applying for financial assistance.
Invalid Input
Initial Here
(*)
Invalid Input
ACCEPTED BY
(*)
I the undersigned have read and understand the Hippotherapy Contract. In addition, I have received, read and understand the General Conduct Policies and Rules for CAN-TR and the member farm. I agree to abide by this contract and the policies stated in these documents. I further understand that if any of the CAN-TR and member farm policies or rules are not followed, CAN-TR and its member farm have the right to cancel this contract in full without any refund of monies remaining for this session.
Invalid Input
I am the
(*)
Rider
Parent
Guardian
Invalid Input
Digital Signature (Full Name)
(*)
Invalid Input
If under the age of 18, the parent/legal guardian must sign. This is a digital signature. By typing your name, you are signing this document.
Digital Signature (Full Name)
(*)
Invalid Input
If under the age of 18, the parent/legal guardian must sign. This is a digital signature. By typing your name, you are signing this document.
Witness:
Digital Signature (Full Name)
(*)
Invalid Input
Must be 18 years of age or older to sign. This is a digital signature. By typing your name, you are signing this document.
WARNING: Under NC Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities. -Chapter 99E of the NC General statutes.
Please enter the characters you see here
Refresh
Invalid Input
Submit Form